First Time Evaluation Form

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The information provided in this form is strictly confidential.

Please complete this form carefully. The information provided will help us build a personalised healthcare programme for you.

Please do not take any supplements for 2 meals prior to your first evaluation.

(fields marked with * are required)

Biographical Details
First Name*
E-mail*

Mailing Address*

Blood Type*
Weight (Kg)
Height (cm)
Date of Birth*
Age (Years)
Gender

Current Occupation*
Marital Status*
Referring Practitioner
Chief Concerns
Please list your current health concerns and rate their severity (on a scale of 1 – 10, 10 being most severe)

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Health History
Please provide a detailed timeline of your personal health history, from childhood. Include all major traumas (physical and emotional), operations and illnesses, the age you were and what changes you experienced in your health.

2500 characters remaining
Other Therapies
If you have tried therapies to help these issues in the past, what was successful and what was not?

1000 characters remaining
Medications
Please list any medications you are currently taking, including self-prescribed medications such as Panadol etc.

Name: Length of use: Dose:
Name: Length of use: Dose:
Name: Length of use: Dose:
Name: Length of use: Dose:
Name: Length of use: Dose:
Supplements
Please list supplements that you currently take and include brand names.

Name: Length of use: Dose:
Name: Length of use: Dose:
Name: Length of use: Dose:
Name: Length of use: Dose:
Name: Length of use: Dose:
Health Overview
Energy

Please rate your current energy level (on a scale of 1-10, 10 being the highest energy)

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Does your energy change through the day and if so how does the scale change:

Other:
Sleep

How is your sleep?

RestfulRestlessHard to get to sleepWake oftenGet up during nightBad dreams

Other
What time do you usually sleep?
How many hours per night?
Exercise
What kind of exercise do you do?
How often do you exercise?
For how long at a time?
Stress

Please rate your current stress level (scale of 1-10, 10 being highest)

1
What is the main reason for your stress?
What steps are you taking to reduce your stress level?
Emotional
Please list any psychological or emotional issues that you are currently experiencing.
How would you describe your overall mood?
Eyes & Ears

Do you wear glassesContact lensesHad laser eye surgeryCataractsGlaucomaPoor night visionWear hearing aidsHave impaired hearingPoor night visionTinnitus

Other
Sunlight
Hours of natural sunlight you receive daily outside?
Hours of sunlight you receive daily through windows?
Hours spent daily under fluorescent lights?
Urination

How are your daily urinations?
2-3 hoursToo frequentSense of urgencyToo small amountToo large amountBurningDribblingUp several times at night

Other
Digestion

How is your digestion?
AdequatePoorAcid refluxBurp oftenGasBloatingBurning / pain in stomachPain before bowel movementNausea before bowel movement

Other
Bowels

Eliminations per day

Other
Amount
NormalToo littleToo large
Consistency
Easy to passDifficult to passFormedToo hardFalls apart in toiletFloatsSoftLoose

Additional info

Women's Health
Are you pregnant or breastfeeding?
YesNo
Are your periods regular?
YesNo
Have you had a hysterectomy?
YesNo
Are you going through menopause?
YesNo
Had an episiotomy or a C-section?
YesNo
Had an epidural?
YesNo
Have you struggled with fertility/miscarriage?
YesNo
Do you have a history of low Iron levels?
YesNo
Are you experiencing any of the following?

Hot flashesNight SweatsDrop in libidoPainful periodsCramping
Men's Health
Have you experienced a drop in muscular strength, drive or libido?
YesNo

If you answered yes, please explain further:

Pets
Do you have any pets?
YesNo
Is it allowed in all areas of the house?
YesNo

What do you feed your pet(s)?

Do you frequently de-worm your pets?
YesNo
Chemical Exposure
Personal Care & Household Products (please indicate products & brands)

Perfume/Cologne
Hair Product
Shampoo
Cleanser
Hand/Body Lotion
Toothpaste
Make-up
Hair Dye
Nail Polish Remover
Deodorant
Moisturiser
Soap
Shave Cream
Conditioner
Nail Polish

Other chemical exposure from personal care products

Dishwashing
Air Freshener
Fly Spray
Paint
Laundry Soap
Glass Cleaner
Pesticides
All-Purpose
Insecticides
Fertilisers
Toilet Cleaner
Herbicides
Bleach

Other chemical exposure (from garden, work, art chemicals, etc)

Electromagnetic Exposure
How many hours per day do you spend...

Watching TV
0
Computer use
0
On landline phone
0
On mobile phone
0
Wearing a pager
0
Wearing a headset
0
Wearing a watch
0
Wearing hearing aids
0
Travelling by vehicle
0

Language